Cosmetic dentistry’s missing link

on 13 March 2008

Cosmetic dentistry in the UK has seen an explosion in demand in the last 10 years and, if this follows the US model, then we can expect further – but things are a bit different here. UK patients tend to seek more of a natural look and, although the most popular shades are still very light, patients tend to shy away from the whitest of Hollywood whites.

Also, a smaller proportion of UK patients have undergone orthodontics in their teens, so a large number of cases we see are moderate-to-severe crowding and rather less ortho relapse cases than in the US. This has presented us with a set of challenges peculiar to the UK: Demand is high for natural, believable and highly aesthetic smiles from a public with a rapidly increasing ‘dental IQ’, yet many cases, especially those with moderate to severe crowding, are highly complex. Ideally these cases would be carried out with orthodontics either as a stand-alone treatment or with orthodontic pre-alignment prior to cosmetic dental treatment.

Less-visible options such as Invisalign, or fixed lingual appliances, have increased the appeal of orthodontics to adults, but treatment times are long and case acceptance rates low. In fact, many patients rule out long-term orthodontics and will not take advantage of a recommended referral.

Treatment turn-off

This leaves us with a large number of patients looking for a restorative solution to moderate-to-severe crowding. Crowding cases will have some teeth that are either rotated or are buccolingually misplaced relative to the other teeth. In either of these situations, tooth preparations can be very heavy and often require multiple elective endodontics.

Even without pulpal exposure, heavily prepared teeth will be more likely to devitalise in the future and require subsequent endodontic therapy. Regardless of whether patients are informed of this possibility, this is not a practice-building event.

Crowded teeth almost always have uneven gingival levels as well. Unless a patient has a low lip-line, treatment that addresses all the aesthetic concerns will also include osseous crown lengthening procedures. However, crown lengthening cannot always overcome all the issues of misaligned gingival contours. For example, if a tooth is palatally placed, the final restoration can have a highly increased and unnatural emergence profile that is unlikely to satisfy today’s ever more aesthetically demanding patient.

So where does this leave us?

When patients arrive for consultation, we can only advise them fully of what treatments are available and what the pros and cons are. It will then be up to the patient to make an informed decision. When faced with the choice of either long-term orthodontics or having teeth root-treated and prepped to ‘stumps’, many patients will choose no treatment at all.

And some of those who do choose involved restorative treatment still do not achieve an ideal result. This has left us with a huge gap in our armamentarium, resulting in our failure to offer achievable, ideal results to some of our most deserving patients. Until now, that is…

Speedy solution

Removable spring orthodontic aligners have been around for a long time, but a breakthrough in spring and aligner design by a US dentist, Dr Don Inman, has given us a new aligner that works in a fraction of the time of conventional orthodontics. I heard about this Inman Aligner from a colleague, Dr Atif Qureshi, who has been using it on his patients over the last three years and has completed more than 200 cases.

The Aligner is designed to align crowded anterior teeth. It’s not designed to close spaces or to intrude or extrude teeth. Up to 3mm of space is created with Interproximal reduction. The Inman Aligner works with two opposing spring-loaded aligner bars that apply a continuous load over a wide range of movement. This seems to be the key to the incredible speed of treatment and allows cases to be completed with only one appliance.

Despite the speed of movement, it is a relatively comfortable appliance to wear because the ‘peak force’ is not as great as with other systems. I could see the potential for Inman immediately, but approached the claims with a certain amount of scepticism. My first case was a lower crowding case that I know would have taken nine months to a year had I referred for fixed appliance

therapy or treated with Invisalign.

I could scarcely believe it when the case was completed in only seven weeks. Over the following 12 months we carried out more than 100 Inman Aligner cases at The London Smile Clinic and I never cease to be amazed at the results we’ve achieved and the speed of treatments. Most cases are completed in eight to 12 weeks, some a little more, some a little less. Treatment of protrusion cases can be extremely quick – either as a stand-alone treatment or if veneers are still required, then minimal preps are sufficient and elective endodontics are no longer required.

Pre-alignment of crowding cases typically take eight or 10 weeks. Not only are preps more conservative, but these cases now require less crown lengthening and, if veneers are still required, then emergence profiles can now be ideal and aesthetics of the finished cases are far superior.

Visible acceptance

Of course, all orthodontics will relapse if not retained and Inman is no exception. Fixed bonded retainers are easy to fit once the technique has been learnt. If a removable retainer is preferred, the danger is that the patient will stop wearing it and get some relapse. With the Inman aligner though, it can just be replaced and easily return the patient to the finished result. One big concern with Inman was that patients might not wish to have an appliance that was more visible than some of the other options.

However, our patients have all been given the option of Invisalign as well. Without exception, they have all chosen speed over ‘invisibility’. Besides, as a removable appliance it can be taken out for those important business presentations or social events. Now that I am in a position to assess the Inman Aligner over our first year, I can report it has been a resounding success. Our case acceptance has increased dramatically, the aesthetic results are better than ever before and I’m enjoying dentistry more, too.

Conservative approach

The biggest thrill for me is to be able to offer no-compromise cosmetic dentistry to those patients who’d have chosen to have nothing done at all once they had discovered what would be involved. We’ve integrated it fully into the practice, and I now look differently at almost every case. We’ve always been committed to

cosmetic excellence and the promotion of dental health through prevention, ongoing maintenance and a conservative approach. The reality was that to achieve cosmetic excellence, a conservative approach was not always possible.

However, with the arrival of the Inman Aligner we can stick to our principles and offer treatments that are both more ethical and more aesthetic than ever before.

The Inman Aligner is truly the ‘missing link’ that cosmetic dentistry so badly needed.